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AbbVie Patient Assistance Program for Lupron Depot
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PO Box 270
Somerville, NJ 08876
Phone
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(800)222-6885
Fax:
(866)483-1305
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Eligibility
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Must have no prescription coverage for needed medication. Medicare PartD patients considered on exception basis. Income requirements for this program have not been disclosed. Must be a US Resident. |
| Who Can Apply
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Call for application to be faxed, mailed, or download from website. Return application via fax or mail. Patient and Doctor are notified within 2-3 business days. |
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Required
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Diagnosis/Medical Criteria not specified. Doctor must complete and sign application. Patient must complete application, sign and attach a copy of proof of income. |
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Supply
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Amount/Supply varies. Patient or Doctor must contact company for refills. Refill limit not specified. New application must be completed yearly. |
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Ship To
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Ships to Doctor's office within 1-3 business days. |
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Note
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Negative decision may be appealed. |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Lupron Depot injection |
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Printable Application Forms
Applications that patients can fill out and bring to their doctor.
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| Download printable Form AbbVie Patient Assistance Foundation for Lupron Depot |
(Requires Acrobat Reader) 
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Diplomat's Co-Pay Assistance Navigator Program
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Attention FUNDING ASSISTANCE
4100 S Saginaw Street
Flint, MI 48507
Phone
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(877)977-9118
Ext 89864
Fax:
(810)282-0176
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Eligibility
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Insurance determined case by case. Medicare Part D patients are eligible for this program. Income requirements determined case by case. Must be a US resident. Must have medically appropriate condition/diagnosis. |
| Who Can Apply
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Patient or Doctor may call to receive application via fax or mail. May also complete application online. Application is to be mailed or faxed back to company. |
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Required
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Doctor's action will be discussed with patient and Doctor after request is received. Patient must complete application, sign and provide annual income information. Proof of income may be requested by program at any time. Patient and/or Doctor are notified of decision within 1-2 business days. |
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Supply
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Amount requested is sent. Company contacts patient to arrange refills, refill limit varies. Re-applications are determined case by case. |
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Ship To
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Once approved medication is shipped to Patient's home within 2 business days. |
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Note
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Diplomat Specialty Pharmacy is a full service pharmacy that can help patients seek funding assistance for the copay portion of their required medications. Applications can be completed online or Prescription, Demographics and Proof of Income may be faxed to 810-282-0176 Attn: Dorrie |
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Includes Support for This Drug
NOTE: Linked drugs are available for Prescribers to Apply Online now.
Click drug logo or drug name to start online application.
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| Lupron Depot injection |
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